Soldiers' Preferences for Follow-Up Communications with Behavioral Health Providers

Introduction

Previous research has demonstrated value in follow-up communication as a viable intervention for increasing treatment compliance, ¹ increasing knowledge of diagnoses, ² and improving the transition from hospital care to primary care. ³ Multiple behavioral health research studies have focused on interventions that take place following discharge from inpatient psychiatric hospitalization with moderately successful results. ^{4 –7} As we begin to appreciate the objective impact of follow-up care on outcomes, we also must understand the patient perspective. Do patients want to be contacted after they complete primary treatment, and, if so, how?

The primary goal of the current study was to examine Soldiers' preferences for follow-up care and their choices of contact medium. A secondary goal was to assess how Soldiers' stigma for behavioral healthcare might influence their preferences for follow-up. For the purposes of this study, “follow-up care” was considered communication with the patient after an office visit and did not necessarily mean after termination of all care.

Materials and Methods

We surveyed a convenience sample of 38 Army, active-duty Service Members attached to a Warrior Transition Unit (WTU) at a large military installation. Warrior Transition Units provide critical support to Soldiers wounded physically and/or psychologically who are expected to require 6 months of rehabilitative care before transitioning back to their active units, to other duties, or out of military service. The study was approved by the Regional Medical Command Institutional Review Board at the study site.

Participants were predominantly white (63%) male (90%) Soldiers, with a median age of 32 years. All participants were recruited from the waiting room of a social work clinic attached to the Warrior Transition Unit and were actively engaged in outpatient behavioral health treatment.

A paper-and-pencil communication survey was created by researchers at the National Center for Telehealth and Technology based on face-valid items of interest. It was composed of 36 questions asking respondents to rate modes of communication following treatment (e.g., “phone call to your cellphone,” “typed postal mail”) on a 5-point Likert-style scale (from 1=“strongly dislike” to 5=“strongly like”). For each mode of communication, participants rated their concern about privacy with respect to mode of communication on a 5-point Likert-style scale (from 1=“not concerned at all” to 5=“very concerned”). Participants also rated preferences for a variety of potential follow-up strategies for behavioral healthcare, such as “I would like a personal note from my healthcare provider such as a message asking how I am, or a birthday card.” We summarized data in two ways: calculated mean scores of individual items from the scales and aggregated responses of “strongly agree/agree,” “neutral,” or “strongly disagree/disagree” expressed as a percentage of the total response pool.

We assessed perceived stigma in participants using an adaptation of the stigma instrument from Hoge et al., ⁸ who reported it be a valid measure of stigma in an active-duty military population. ^8,9 Participants responded to six Likert-style items about reasons why military personnel may be hesitant to seek care. Example items included “My leaders would blame me for the problem” and “My unit leadership might treat me differently.” Our adapted measure demonstrated good internal consistency (Cronbach's alpha=0.86) with the current sample. We calculated the overall median value (median=20) and split the sample artificially into two groups, “high-stigma” (n=12) and “low-stigma” (n=17), based on participants' total scores in relation to the median. We then ran t tests for independent samples to compare high- and low-stigma participant responses to questions about communication preference.

Results

More than half (51%) of respondents said they “would like” their healthcare provider to call or write to check up on them after an appointment (8% said they would not, whereas 41% were neutral). Nearly all (95%) participants said they “would like or strongly like” a phone call to their cellphone if their healthcare provider was checking up on them after an appointment. A substantial majority of those surveyed (84%) also said they would be interested in an e-mail from a healthcare provider with a link to a Web site about their health condition (5% did not, 11% were neutral), whereas less than a quarter (24%) of respondents preferred a personal note from their healthcare provider such as a message asking how they were or a birthday card (41% disagreed, and 35% were neutral).

In response to the question “If your healthcare provider (for example, a doctor, nurse, or therapist) was checking up on you after an appointment, how much would you prefer the following types of communication?,” participants endorsed the following preferences (in order): (1) call to personal cellphone (mean=4.45), (2) text message (mean=3.74), and (3) e-mail to personal account (mean=3.71). Only minimal concerns about privacy were endorsed for any of the various modes of communication; all mean values were below the midpoint “somewhat concerned” (“3”) response. Of those, highest levels were for postal mail (mean=2.47) and e-mail to a work account (mean=2.39).

We found statistically significant differences for stigma on two items. First, high-stigma participants (t ₂₄=3.15, p=0.004) said they would not like (mean=1.94) a personal note from a healthcare provider (such as a note asking how they were or a birthday card), whereas low-stigma participants were ambivalent (mean=3.33). Second, we asked participants to consider a hypothetical example in which a Service Member had recently been discharged from an inpatient psychiatric hospital. We asked them to indicate how much they agreed (from 1=“strongly disagree” to 5=“strongly agree”) with a series of statements about follow-up care. In response, most high-stigma participants (t ₂₄=2.25, p=0.03) said they felt neutral (mean=3.24) about the provider sending a personal message to the hypothetical patient, but low-stigma participants felt it was a “good idea” (mean=4.17).

Discussion

The literature suggests that provider-initiated follow-up communication can be clinically beneficial. Results of our study indicate that patients, too, are favorably disposed to receiving follow-up communications from healthcare providers, especially via calls to their personal cellphones. Even patients in our sample who were more highly stigmatized against seeking healthcare said they would at least like an e-mail to a non-work account with a link to a Web site with information on their condition.

Our brief study was restricted to a small and primarily homogeneous convenience sample of active-duty Service Members who likely had more privacy concerns and higher levels of stigma than a non-military sample. Given these limitations, the results may not be generalizable far beyond a military or Veteran population, although they may still be indicative of preferences in a behavioral health setting. Nonetheless, important take-away points can be derived from the survey responses. Although communicating with patients after termination of services is not a commonplace practice in the field of clinical psychology, a growing field of literature demonstrates that this may be a useful tool to improve outcomes with patients.